Unpaid labour is a neglected social determinant of health
Authors: Anne McMunn
Journal: The Lancet Public Health (2023)

An important social determinant of health is work.1Burgard SA Lin KY Bad Jobs, Bad Health? How work and working conditions contribute to health disparities.Am Behav Sci. 2013; 57: 1105-1127Crossref Scopus (163) Google Scholar Although employment generally benefits health through a range of material and psychosocial factors, the health benefits of work vary by stress-related factors such as security, pay, hours and autonomy.2Chandola T Zhang N Re-employment, job quality, health and allostatic load biomarkers: prospective evidence from the UK Household Longitudinal Study.Int J Epidemiol. 2018; 47: 47-57Crossref PubMed Scopus (62) Google Scholar Yet, employment might be only half of the story when it comes to understanding work and health. Unpaid labour has been largely ignored. Some of the well-documented work stress factors found in some sectors might also be found in unpaid labour, and unpaid labour might influence health indirectly through its impact on employment outcomes and opportunities. Women continue to do more unpaid labour than men in all countries,3Craig L Mullan K How mothers and fathers share childcare: a cross-national time-use comparison.Am Sociol Rev. 2011; 76: 834-861Crossref Scopus (355) Google Scholar and women remain more likely than men to reduce work hours in response to care responsibilities, and work in low paid and precarious sectors. Women also continue to earn less than men and are under-represented in decision-making roles, and gender inequality in the distribution on unpaid labour is thought to contribute to these differences.4Harkness S Borkowska M Pelikh A Employment pathways and occupational change after childbirth. Government Equalities Office, London2019Google Scholar, 5Office for National StatisticsGender pay Gap in the UK: 2022.https://www.ons.gov.uk/employmentandlabourmarket/peopleinwork/earningsandworkinghours/bulletins/genderpaygapintheuk/2022Date: Oct 22, 2022Date accessed: February 16, 2023Google Scholar, 6Ferrant G Pesando LM Nowacka K Unpaid care work: the missing link in the analysis of gender gaps in labour market outcomes.https://www.oecd.org/dev/development-gender/Unpaid_care_work.pdfDate: 2014Date accessed: February 24, 2023Google Scholar The study by Jennifer Ervin and colleagues7Ervin J Taouk Y Hewitt B King T The association between unpaid labour and mental health in working-age adults in Australia from 2002 to 2020: a longitudinal population-based cohort study.Lancet Public Health. 2023; 8: e276-e285Summary Full Text Full Text PDF Scopus (1) Google Scholar published in this issue of The Lancet Public Health provides an important contribution on this neglected public health topic. Using fixed-effects models on 19 waves of Household, Income and Labour Dynamics survey in Australia, this study uses rigorous techniques in a long-running, high-quality, nationally representative panel survey to investigate associations between unpaid labour and mental health amongst both men and women. Three previous longitudinal studies on this topic found increasing hours in unpaid labour to be associated with worse mental health among women.8Gilbert-Ouimet M Brisson C Vézina M Psychosocial work stressors, high family responsibilities, and psychological distress among women: a 5-year prospective study.Am J Ind Med. 2020; 63: 170-179Crossref PubMed Scopus (15) Google Scholar, 9Owoo NS Lambon-Quayefio MP Mixed methods exploration of Ghanaian women's domestic work, childcare and effects on their mental health.PLoS One. 2021; 16e0245059Crossref PubMed Scopus (11) Google Scholar, 10Peristera P Westerlund H Magnusson Hanson LL Paid and unpaid working hours among Swedish men and women in relation to depressive symptom trajectories: results from four waves of the Swedish Longitudinal Occupational Survey of Health.BMJ Open. 2018; 8e017525Crossref PubMed Scopus (13) Google Scholar However, Ervin and colleagues7Ervin J Taouk Y Hewitt B King T The association between unpaid labour and mental health in working-age adults in Australia from 2002 to 2020: a longitudinal population-based cohort study.Lancet Public Health. 2023; 8: e276-e285Summary Full Text Full Text PDF Scopus (1) Google Scholar investigate different unpaid labour forms (housework, childcare, and adult care) separately, revealing important differences. Some forms of unpaid labour seemed to be protective and there were important gender differences along what might be seen as traditional lines. Hours spent doing housework was associated with worse mental health for both men (β coefficient=−0·026 [95% CI −0·04 to −0·01]) and women (β coefficient=−0·009 [−0·02 to 0·001]) whereas care work was only associated with mental health for women and hours spend doing outdoor work was associated with improvements in mental health for men (β coefficient=0·067 [0·04 to 0·09]). The effect of care work on women's mental health was very different depending on the care recipient, with increasing time spent in adult care being associated with worse mental health (β coefficient=−0·027 [−0·04 to −0·01]) but time spent in childcare associated with improvements in mental health (β coefficient=0·016 [0·01 to 0·02]). As has been seen in the paid work literature, these results suggest that the quality and characteristics of care work matter when it comes to its effect on mental health. Although both childcare and adult care are potentially high demand, low control activities, they differ in important ways. For example, childcare is often by choice and adult care is often the result of the functional decline of a loved one. A key take home message from this work, then, is that each form of unpaid labour ought to be studied separately as potentially distinct social determinants of health, a departure from much of the previous research in this area which has tended to combine time use data on the range of unpaid labour forms together.8Gilbert-Ouimet M Brisson C Vézina M Psychosocial work stressors, high family responsibilities, and psychological distress among women: a 5-year prospective study.Am J Ind Med. 2020; 63: 170-179Crossref PubMed Scopus (15) Google Scholar, 9Owoo NS Lambon-Quayefio MP Mixed methods exploration of Ghanaian women's domestic work, childcare and effects on their mental health.PLoS One. 2021; 16e0245059Crossref PubMed Scopus (11) Google Scholar, 10Peristera P Westerlund H Magnusson Hanson LL Paid and unpaid working hours among Swedish men and women in relation to depressive symptom trajectories: results from four waves of the Swedish Longitudinal Occupational Survey of Health.BMJ Open. 2018; 8e017525Crossref PubMed Scopus (13) Google Scholar Although gender differences in the total burden of combined labour types remains an important focus of research from a gender equity perspective, the findings by Ervin and colleagues remind us that labour is not homogenous when it comes to its effects on mental health; variation in the characteristics and qualities of all forms of work matter and this might be as true for unpaid labour as it is for the paid labour. It is also important to note that the effect sizes in this study were small for each of the labour forms studied. These findings suggest that unpaid labour is part of a boarder picture of social determinants. Future work might look at how these determinants cluster or interact with one another to form subgroups at risk, such as long hours of housework or adult care in the context of socioeconomic disadvantage. It will also be important to replicate this study in other country and cultural contexts. It will be useful to see if childcare and outdoor work are protective for the mental health of women and men respectively in Nordic countries, for example, where gender norms are more egalitarian than in many countries. Finally, theoretical development regarding the mechanisms linking unpaid labour and health is crucial to understand, measure, and study appropriate aspects of unpaid care work in population health research. I declare no competing interests. The association between unpaid labour and mental health in working-age adults in Australia from 2002 to 2020: a longitudinal population-based cohort studyThis study reveals considerable variance and nuance in how different domains of unpaid labour affect mental health, as well as continued inequity in the division of unpaid labour in households, with women doing considerably more unpaid labour than men. This study also exposes important challenges associated with measuring and understanding total (combined) unpaid labour as a determinant of health. Full-Text PDF Open Access